WASTING AS INDEPENDENT RISK FACTOR FOR MORTALITY IN CHRONIC HEART-FAILURE

Background Wasting in chronic heart failure (CHF) has long been known but is little investigated. We sought to find out whether the cachecti c state in CHF provides additional prognostic information about all-ca use mortality. Methods Between June, 1993, and May, 1995, we studied 1 71 consecutive patients with CHF (mean age 60 years [SD 11; range 27-8 6]; 17 female). We assessed exercise capacity (peak oxygen consumption ; mean 17.5 mL kg(-1) min(-1) [6.7]), functional status (New York Hear t Association [NYHA] class: 21 class I, 63 class II, 68 class III, 19 class IV), and left-ventricular ejection fraction (mean 30% [SD 15]; n =115). The cachectic status was defined prospectively as a non-intenti onal documented weight loss of at least 75% of previous normal weight (28 patients; range 9-36% or 6-30 kg) during at least 6 months. The Co x proportional-hazards model was used to assess the association of var iables with survival, and Kaplan-Meier cumulative survival plots were constructed to estimate the influence of risk factors. Findings At the end of follow-up in November, 1996, 49 patients had died (after a mea n 324 days [SD 283]). The mean follow-up of the survivors was 834 days (SD 186; range 549-1269). The cachectic state was predictive of 18-mo nth mortality independent of age, NYHA class, left-ventricular ejectio n fraction, and peak oxygen consumption. Mortality in the cachectic pa tients (n=28) was 18% at 3 months, 29% at 6 months, 39% at 12 months, and 50% at 18 months. Patients who had a peak oxygen consumption below 14 mL kg(-1) min(-1) (n=53) had mortality at 3, 6, 12, and 18 months of 19%, 30%, 40%, and 51%. 18-month survival was 23% (95% CI 0-46) for the 13 patients with both of these risk factors (cachexia and low pea k oxygen consumption) compared with 93% (88-98) in those (n=103) with neither risk factor (p<0.0001). Interpretation The cachectic state is a strong independent risk factor for mortality in patients with CHF. C ombined with a low peak oxygen consumption, it identifies a subset of patients at extremely high risk of death. Assessment of cachexia shoul d be included in transplant programmes and studies that investigate th e effect of interventions by survival analyses.